Friday Feedback: Will New BP Target Change Practice?

More than 100 million Americans now qualify for hypertension diagnosis

The American Heart Association and American College of Cardiology recently lowered the national blood pressure target from 140/90 mm Hg to 130/80 mm Hg for the general population, in a guideline endorsed by nine additional groups. The new guidelines mean that more than 100 million Americans now qualify for hypertension diagnosis and suggest that newly diagnosed individuals be managed with lifestyle interventions instead of drugs when possible.

Questions have been raised, however, about whether the new target was excessively influenced by the controversial SPRINT trial -- which found a significant benefit for intensive treatment to a target of 120/80 mm Hg -- given ongoing concern that those results were confounded by methodological problems.

MedPage Today reached out to experts for their thoughts on the clinical implications of the new guidelines.

How will the new guideline change your practice, if at all?

John Bisognano, MD, PhD, University of Rochester Medical Center and president of the American Society of Hypertension: The guidelines will make a substantial change in how I treat patients. Most importantly, we recognized blood pressure over 120/80 as elevated and can now counsel them intensely on lifestyle changes. They're essentially on a moving sidewalk toward a destination of heart attack, stroke, and kidney disease -- and previously we'd just raise concern as they were really close to the destinations. We don't have to wait anymore.

Martha Gulati, MD, FACC, University of Arizona College of Medicine and American Heart Association spokesperson: Ultimately there is no longer the word "prehypertension" and I think that is good because with the cutoff as set in the new guidelines, it will make physicians pause and hopefully be more aggressive in treating patients with lifestyle changes and medications where appropriate. Intensive treatment has better outcomes and ultimately this should be our goal. I think it is important to acknowledge that we are not great at treating BP even with higher thresholds. People often aren't at goal and this is a major problem. When we treat BP we can reduce MIs and stroke. Maybe this can change just by this lower threshold.

Jackson Wright, MD, PhD, University Hospitals Cleveland Medical Center and lead investigator in the SPRINT trial: The new national guidelines will of course and hopefully change practice. Hypertension is the leading cause of death from cardiovascular disease and second to only cigarette smoking as the leading cause of death from any cause in the U.S. The recommendations included in this guideline are the result of the unanimous agreement by all the experts and major professional organizations agreeing to participate in developing this publication.

Upendra Kaul, MD, DM, Batra Hospital and Medical in New Delhi: Certainly, it has already changed in the last 2 days. I have become more aggressive in meeting the target of <130/80, especially in patients at higher risk.

Sanjay Kaul, MD, FACC, Cedars-Sinai Medical Center: Not really! I subscribe to the philosophy (as I am sure many others do) espoused by the conclusion drawn by a report evaluating the quality of evidence underlying guideline recommendations: "Exercise caution when considering recommendations not supported by solid evidence!"

Do you think the science underlying the new guideline is sufficiently robust?

Upendra Kaul: Yes, the SPRINT trial and a number of meta-analysis have very robust data. The new guidelines have endorsed the findings and very rightly so.

Bisognano: The Committee reviewed hundreds of clinical trials on patients with a whole variety of disease states. The data is extraordinarily robust and truly makes sense. As there were doubters in the 1960s regarding the utility of treating blood pressure at all, there will also be skeptics about these new more intensive guidelines as well -- and it may just take time for those people to appreciate the richness of the evidence and the huge amount of good that we can do for our patients with these lower targets.

Gulati: I do think the science behind these guidelines is robust. We have large blood pressure trials showing more intensive treatment improves outcomes. SPRINT was a good study -- not perfect -- but strong and heavily influenced these guidelines. I will admit that I criticized SPRINT for not having enough women, specifically not enough elderly women.

John B. Kostis, MD, DPhil, Rutgers Robert Wood Johnson Medical School: The science is very robust from the evidence-based medicine point of view. However, most of the evidence has a horizon of 5 years or less which may not be sufficiently long. Also, there is no sensitivity analysis to include additional observational data.

Sanjay Kaul: The quality and the quantity of the evidence derived from SPRINT is not credible enough to inform guidelines or guide clinical practice. In a treat-to-target trial, the target has to be accurately measured with predefined protocols to minimize variation in the measurement. In addition, the open label nature of the trial design, the amount of missing data and the premature truncation of the trial further detract from the ability of the trial to reliably inform clinical practice. Given these limitations, the guideline writers took a middle ground approach for setting BP treatment target which might be open to criticism from partisans on both extremes.

What unintended consequences from the new guideline do you worry about, if any?

Sanjay Kaul: Disease mongering and medicalization are two major concerns. When was the last time a professional medical society raised, instead of lowering, disease thresholds? Perhaps the new BP thresholds could be used to define wellness and promote health via non-pharmacologic approaches, i.e., lifestyle intervention.

Bisognano: I only worry that in defining 46% of people with a disease, some people may view it as a condition so common that intensive attention is not always warranted -- like a little arthritis, wrinkles, or lower back pain that might come with normal aging. I see it as an explanation why cardiovascular disease remains our number one killer and a new pathway to reach the large number of people who are on the moving sidewalk toward heart attack, stroke, and kidney disease before they are actually there, suffering the consequences. I am also concerned that some might have a lackluster enthusiasm to push toward lower goals out of fear of rampant side-effects.

Gulati: I think there is somehow an idea that these guidelines are to drive medication use. I see it quite differently. Just being categorized as hypertensive doesn't mean you automatically need medication. In fact, a lot of those who fall in the new category of Stage 1 hypertension don't need medications unless they are high risk or already have ASCVD.

We just don't always know, as healthcare professionals, how to implement or work with patients on lifestyle changes. We need to engage the patient and make this a shared and informed decision of how we will tackle their blood pressure. Hopefully physicians spend the time helping patients with lifestyle changes and don't just think that everyone needs medications. Lifestyle changes can be far more powerful than any one medication, so we need to start there and constantly work on this with our patients.

Wright: The evidence is clear that many lives would be saved and disabilities prevented if the recommendations in this guideline were implemented. Unintended consequences would be the refusal or inability of providers and care systems to accommodate them.

Gibbons: Some low-risk patients will misunderstand news stories and expect medications rather than lifestyle change. Primary care providers will spend a lot of time-in person and on the phone explaining this issue.

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